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Take the "hyper" out of pharmacotherapy

Messina, Barbara Ann M. PhD, RN, ANP; Escallier, Lori A. PhD, RN, CPNP

doi: 10.1097/01.NURSE.0000395208.11108.83
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Chances are, many of your older patients are taking more medications than they need. These tips and guidelines will help you assess their drug regimen and eliminate medications that increase their risk of falls and other complications.

Barbara Ann M. Messina is a clinical associate professor in the School of Nursing/Department of Adult Health and an adjunct clinical associate professor in the School of Medicine/Department of Pharmacology at the State University of New York at Stony Brook. Lori A. Escallier is clinical professor and associate dean, School of Nursing, State University of New York at Stony Brook.

ACCORDING TO THE U.S. CENSUS BUREAU, 38.9 million adults celebrated their 65th birthday between 1996 and 2010. The Census Bureau projects that by 2050, the number of Americans over age 65 will more than double to 88.5 million, representing nearly 20% of the population.1

With increasing age comes the increasing likelihood of chronic diseases treated with multiple drugs. This article discusses the perils of multiple medications in older adults and explores strategies for preventing avoidable adverse reactions related to complex drug regimens.

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Challenging healthcare needs

As the population ages, the healthcare system will be challenged to shift its emphasis from acute care to meeting the needs of chronically ill older adults, who typically require therapy with multiple drugs. For example, many patients with heart failure are treated with five or more medications.2–5

Among patients age 55 and older, the most common diseases requiring pharmacotherapy (drug therapy) are arthritis, depression, heart disease, hypertension, and diabetes. When a patient is being treated for more than one chronic illness—for example, heart failure and diabetes—the drug burden and risk of adverse reactions increase exponentially.6

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Polypharmacy or hyperpharmacotherapy?

Polypharmacy is often defined as the use of multiple medications to treat health problems.7 It's come to represent the inappropriate use of multiple medications rather than the rational use of concomitant drugs. Other ways of describing polypharmacy include bottle proliferation, an excessive number of prescriptive agents, high-frequency medications, multiple-dose medications, unnecessary use of medications, or use of more medications than are clinically indicated.8–11 Currently the preferred term to describe the excessive use of drugs to treat disease is hyperpharmacotherapy, because polypharmacy has taken on various meanings, including patients' use of multiple pharmacies to fill prescriptions.12,13

To reduce hyperpharmacotherapy, perform frequent medication reconciliation for each patient while asking yourself this question: "Is every medication in this patient's regimen clinically indicated and prescribed at the lowest effective dosage?" If the answer is no, notify the prescriber to determine if changes in the drug regimen are indicated.

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Healthy People strategies

Sponsored by the U.S. Department of Health and Human Services, the Healthy People (HP) initiatives (HP 2010 and HP 2020) are evidence-based 10-year national objectives for improving Americans' health. The following HP strategies, designed to coordinate healthcare between patients, their families, prescribers, and other healthcare providers, can reduce or eliminate excessive, inappropriate, or potentially harmful medication use.6

  • Assess the patient's drug regimen, including prescription, over-the-counter (OTC), and complementary therapies, and nutritional supplements.
  • Determine whether each drug is truly indicated. Is a better nonpharmacologic alternative available?
  • The prescriber should choose a drug that takes into account patient characteristics (such as impaired renal function and physical limitations secondary to chronic conditions) and encourage adherence to therapy.
  • The prescriber should begin with a low dose and increase the dose as necessary until the desired therapeutic effect is achieved.
  • The prescriber should use the fewest number of drugs possible and eliminate any that aren't useful.
  • When starting a new drug, inform the patient about possible adverse reactions, including those that should be reported to the healthcare provider immediately.
  • Consider the possibility that any new signs or symptoms could represent an adverse drug reaction (ADR) or drug withdrawal.
  • Encourage frail older patients to have a close friend, relative, or caregiver accompany them to healthcare appointments, and apprise this person of changes in the drug regimen (with the patients' permission).
  • Provide a portable prescription record that can be taken to other practitioners.
  • Encourage patients to use only one pharmacy or pharmacy chain. Having one centralized record of all prescriptions helps prevent ADRs.
  • Stay informed about pharmaceutical innovations and ongoing research into age-related changes in pharmacokinetics in order to reduce the risk of adverse reactions in older adults.8
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Communication is key

Good communication is the foundation of every healthcare interaction. Poor communication has been linked to misdiagnoses, unnecessary diagnostic studies, and failure to adhere to pharmacotherapeutic treatment plans. Studies have shown that good communication increases patients' adherence to pharmacotherapeutic treatment plans and reduces the incidence of ADRs. Communication has been cited as the single most important tool that nurses can use to enhance the delivery of safe and effective healthcare.14–17

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Listen to your patients

You may be an expert at patient care, but your patients are the experts at running their own lives. Patients are the best source of information about the attitudes, beliefs, and habits that govern their lives and affect their acceptance of treatment.16,17 As such, they themselves are the most effective diagnostic "tool" that nurses possess. By attending to your patients' concerns and preferences, you can assess personal and cultural behavior that may affect their adherence to treatment.

To help you gather information, the HP initiative provides a tool you can use when taking your patient's history and performing drug reconciliation. See How to talk to your patient for suggested assessment questions and interventions. You should relay the information you gather to other members of the multidisciplinary healthcare team. A study conducted by McGaw, et al., found a reduction in ADRs and an increase in patient adherence to patient pharmacotherapeutic treatment regimens when a multiple disciplinary medication reconciliation treatment approach was employed.18

Follow-up visits are a crucial component of the patient's pharmacotherapeutic treatment plan. Educate patients and families so they understand that treatment of chronic disease isn't an episodic event, but rather a process that requires long-term care and continuous communication with the healthcare team.

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Improved patient outcomes

Nurses play an integral role in improving patient outcomes. A multidisciplinary approach to pharmacotherapy has been shown to increase medication adherence, reduce hyperpharmacotherapy, and reduce the incidence of ADRs, all of which improve patients' quality of life.

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How to talk to your patient6

A questionnaire developed for the HP initiative can be filled out by the patients and family members at each office visit and used as a guide while eliciting patient information during the history and physical exam.

Questions to ask patients

  • Do you take five or more prescription medications?
  • Do you take herbs, vitamins, other dietary supplements, or OTC medications?
  • Do you get your prescriptions filled at more than one pharmacy?
  • Is more than one healthcare practitioner prescribing your medications?
  • Do you take your medications more than once a day?
  • Do you have trouble opening your medication bottles?
  • Do you have poor eyesight or hearing?
  • Do you live alone?
  • Do you have a hard time remembering to take your medications?

Suggestions to offer patients

  • If you have more that one healthcare provider, make sure that each one knows what the others are prescribing.
  • Ask your primary healthcare provider whether you need to take all the medications on the list and whether you can reduce any of the dosages.
  • Always read labels; they may help you avoid a possible drug interaction.
  • Always get your prescriptions filled at the same pharmacy or pharmacy chain.
  • Learn the names of your medications and why you take them.
  • Avoid nonprescription combination products such as cold remedies. Ask your healthcare provider or pharmacist for help buying only the specific medication that treats the symptoms you are experiencing.
  • Never take any new drug without discussing possible adverse reactions and interactions with your healthcare provider or pharmacist.
  • If you feel that you're taking too many medications or if you're confused about the number or quantity of medications you're taking, talk to your healthcare provider.
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REFERENCES

1. U.S. Department of Commerce. Older Americans Month: May 2010. U.S Census Bureau News. 2010 .
2. Moser DK, Watkins JF. Conceptualizing self-care in heart failure: a life course model of patient characteristics. J Cardiovasc Nurs. 2008;23(3):205–218.
3. Corsonello A, Pedone C, Corica F, Incalzi RA. Polypharmacy in elderly patients at discharge from the acute care hospital. Ther Clin Risk Manag. 2007;3(1):197–203.
4. Ballentine NH. Polypharmacy in the elderly: maximizing benefit, minimizing harm. Crit Care Nurs Q. 2008;31(1):40–45.
5. Volpe M, Chin D, Paneni F. The challenge of polypharmacy in cardiovascular medicine. Fundam Clin Pharmacol. 2010;24(1):9–17.
6. U.S. Department of Health and Human Services. Healthy People 2020 .
7. The American Heritage Dictionary of the English Language. 4th ed. Boston, MA: Houghton Mifflin Company; 2006.
8. Cooney D, Pascuzzi K. Polypharmacy in the elderly: focus on drug interactions and adherence in hypertension. Clin Geriatr Med. 2009;25(2):221–233.
9. Loya AM, González-Stuart A, Rivera JO. Prevalence of polypharmacy, polyherbacy, nutritional supplement use and potential product interactions among older adults living on the United States-Mexico border: a descriptive, questionnaire-based study. Drugs Aging. 2009;26(5):423–436.
10. Salazar JA, Poon I, Nair M. Clinical consequences of polypharmacy in elderly: expect the unexpected, think the unthinkable. expert Opin Drug Saf. 2007;6(6):695–704.
11. Steinman MA. Polypharmacy and the balance of medication benefits and risks. Am J Geriatr Pharmacother. 2007;5(4):314–316.
12. Zarbock S. Hyperpharmacotherapy in someone you love. JAAPA. 2005;18(9):12–13.
13. Bushardt RL, Massey EB, Simpson TW, Ariail JC, Simpson KN. Polypharmacy: misleading, but manageable. Clin Interv Aging. 2008;3(2):383–389.
14. Spinewine A, Schmader KE, Barber N, et al. Appropriate prescribing in elderly people: how well can it be measured and optimised? Lancet. 2007;370(9582):173–184.
15. Catalano K, Fickenscher K. Complying with the 2008 National Patient Safety goals. AORN J. 2008;87(3):547–556.
16. Langer N. Integrating compliance, communication, and culture: delivering health care to an aging population. Educ Gerontol. 2008;34(5):385–396.
17. Christen RN, Alder J, Bitzer J. Gender differences in physicians' communicative skills and their influence on patient satisfaction in gynaecological outpatient consultations. Soc Sci Med. 2008;66(7):1474–1483.
18. McGaw J, Conner DA, Delate TM, Chester EA, Barnes CA. A multidisciplinary approach to transition care: a patient safety innovation study. Permanente J. Fall 2007;11(4) .
© 2011 Lippincott Williams & Wilkins, Inc.